Stress Urinary Incontinence in Women: Diagnosis and Medical Management

Mark Deutchman, MDMedical Writer: Meghan Wulster-Radcliffe, PhD

Diagnosis

Table 1 lists the definitions of various forms of urinary incontinence.^[1,2] SUI is the most common form of urinary incontinence, occurring in pure or mixed forms in nearly 80% of women with incontinence, according to 2 European studies.^[8,9] Urge incontinence (UUI), or "overactive bladder," is the second most common type of urinary incontinence. UUI is characterized by the unexpected loss of urine while suddenly feeling the need to urinate. Mixed urinary incontinence (MUI) is a term that applies to a combination of symptoms (SUI and UUI) and to a combination of urodynamic conditions (urodynamic stress incontinence and detrusor overactivity). Typically, women with MUI symptoms have more severe and bothersome incontinence than women with only SUI or UUI.^[8,10] It has recently been proposed that these mixed symptoms are the result of, rather than the cause of, more severe SUI.^[11,12] With urodynamic testing, MUI may be subclassified into more specific diagnoses.

The 2005 International Consultation on Incontinence (ICI) developed a series of guidelines, including a clinical algorithm for the initial management of women with UI.^[1] The ICI algorithm recommends that the assessment include a targeted medical history and assessment of quality of life, a general assessment, and a focused physical examination before arriving at a presumed diagnosis and initiating treatment. The need to simplify this algorithm has been addressed.^[13]

A patient history should include consideration of the underlying risk factors listed in Table 2 , as well as potentially reversible causes described in Table 3 .^[14] In practical experience, in the primary care setting, a history based on eliciting underlying risk factors, reversible causes, and the symptoms listed in Table 1 will help identify patients with SUI or UUI. In the case of patients with mixed symptoms, it may be necessary to clarify the source of the symptoms. Asking the patient to keep a bladder record such as the one available for download from the National Library of Medicine at https://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.table.32903 can help clarify symptoms.^[15]

A focused physical examination is described in Table 4 . A urinalysis should be performed on all patients with incontinence to rule out pyuria (infection), hematuria (infection, stones, or cancer), proteinuria (renal disease), and glycosuria (diabetes).

A stress pad test -- either a short-term test conducted in the office or a long-term test conducted at home -- is also useful as an optional investigative tool. The test measures the amount of leakage that occurs when the patient performs a series of activities that might trigger urine leakage (eg, jumping, climbing stairs, coughing vigorously, performing deep knee bends, or washing hands). A pad weight gain ≥ 1 g is considered positive for the 1-hour test, whereas a weight gain ≥ 4 g is considered positive for the 24-hour test.^[16] Controversy exists about the reproducibility and validity of these tests, and the 1-hour test is not very accurate unless a fixed bladder volume is confirmed via catheterization or ultrasound.^[16]

The results of the history, physical examination for stress-induced leakage, and bladder catheterization for postvoid residual urine volume will identify the majority of patients with SUI or MUI and distinguish them from those with primarily overactive bladder. Those who can be assumed to have SUI or MUI will have a history of leaking with coughing or straining, will demonstrate leakage when asked to cough or "bear down" during the physical examination, will have a postvoid residual urine volume of < 50 to 100 mL, and will have a normal urinalysis. Bladder catheterization is no longer recommended as an obligatory assessment for all women. However, it should be considered in women with neurologic disease, severe pelvic organ prolapse, or a history of prior incontinence surgery or radical pelvic surgery. Although specialized urodynamic testing can be performed to more precisely differentiate between SUI and UUI, the results of such testing have indicated that a high percentage of those with MUI symptoms are classified in the stress category rather than the urge category.^[17] It is therefore reasonable to consider initiating treatment for SUI in any patient with significant symptoms of SUI without performing urodynamic testing.

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Cite this: Stress Urinary Incontinence in Women: Diagnosis and Medical Management - Medscape - Dec 06, 2005.

Types of Urinary Incontinence ^[1,2]
Stress	Involuntary leakage on effort or exertion, or on sneezing or coughing
Urge	Involuntary leakage accompanied by or immediately preceded by urgency
Mixed	Involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing
Functional	Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet
Overflow	Unexpected leakage of small amounts of urine because of an overfilled bladder
Transient	Leakage that occurs temporarily because of a condition or situation that will pass (eg, infection, medication)
Deformity	Fistula or developmental abnormality

Risk Factors for Urinary Incontinence ^[8]
Estrogen depletion
Diabetes
Childhood nocturnal enuresis
Morbid obesity
Race
Smoking
Fecal impaction
Delirium
Low fluid intake
High-impact physical activities
Environmental barriers
Stroke or impaired cognition
Immobility/chronic degenerative disease
Pelvic muscle weakness
Pregnancy/vaginal delivery/episiotomy
Medications: Diuretics Caffeine Alcohol Beta-adrenergic agonists Alpha-adrenergic agonists Alpha-adrenergic blockers Narcotic analgesics Anticholinergic agents Calcium channel blockers Psychotropics Angiotensin converting enzyme inhibitors

Management of Reversible Conditions That Cause or Contribute to Urinary Incontinence ^[7]
Condition	Management
Urinary tract infection	Antimicrobial therapy
Atrophic vaginitis/urethritis	Oral or topical estrogen
Pregnancy/vaginal delivery	Behavioral intervention (Avoid surgical therapy postpartum, as condition may be self-limiting.)
Stool impaction	Disimpaction -- stool softeners, bulk-forming agents, and laxatives, if necessary; high fiber intake, adequate mobility and fluid intake
Medications (see Table 2)	Discontinue or change therapy, reduce dosages; modify diuretic schedule.
Metabolic disorder (hyperglycemia, hypercalcemia)	Better control of diabetes mellitus (Therapy for hypercalcemia depends on underlying cause.)
Excess fluid intake	Reduction in intake of diuretic fluids (eg, caffeinated beverages)
Venous insufficiency with edema	Support stocking, leg elevation, sodium restriction, diuretic therapy
Congestive heart failure	Medical therapy
Delirium	Diagnosis and treatment of underlying cause(s) of acute confusional state
Illness, injury, or restraint that interferes with mobility	Regular toileting, environmental alterations (eg, bedside commode, urinal)
Psychological	Removal of restraints if possible; appropriate pharmacological and/or nonpharmacologic treatment

Types of Urinary Incontinence ^[1,2]
Stress	Involuntary leakage on effort or exertion, or on sneezing or coughing
Urge	Involuntary leakage accompanied by or immediately preceded by urgency
Mixed	Involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing
Functional	Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet
Overflow	Unexpected leakage of small amounts of urine because of an overfilled bladder
Transient	Leakage that occurs temporarily because of a condition or situation that will pass (eg, infection, medication)
Deformity	Fistula or developmental abnormality

Focused Physical Examination in the Patient With Urinary Incontinence
Neurologic disease that could affect spinal cord function, mobility, or cognition Peripheral edema or abdominal ascites Rectal examination: Perineal sensation Rectal muscle tone Masses Fecal impaction Vaginal examination: Vaginal atrophic changes indicating estrogen deficiency Pelvic organ prolapse Pelvic masses Urethral discharge or tenderness Leakage from a fistula or other developmental abnormality Direct observation of urine loss when asking the patient to cough or "bear down" in the presence of a full bladder but before there is an urge to void (If no leakage occurs in the lithotomy position, repeat the test in the standing position.) Bladder catheterization for postvoid residual urine volume (Residual volume should be < 50 to 100 mL.)

Pharmacologic Therapy for Urinary Incontinence in Women
Class of Agent	Specific Agent	Condition
Topical or vaginal estrogen	Conjugated estrogen	Vaginal atrophy
Anticholinergic agents	Tolterodine Oxybutynin Propantheline Darifenacin Solifenacin	Urge incontinence (overactive bladder)
Tricyclic antidepressants	Imipramine^*	Mixed and stress urinary incontinence
Alpha-adrenergic agonists	Pseudoephedrine ^*	Stress urinary incontinence
Selective serotonin and norepinephrine reuptake inhibitor	Duloxetine ^†	Stress urinary incontinence

^*Off-label usage
^†Approved for treating SUI in the European Union but not in the United States

Surgical Options for Treatment of Urinary Incontinence
Retropubic urethropexies (Burch and Marshall-Marchetti-Krantz procedures)
Suburethral sling ("tension-free vaginal tape")
Periurethral injection of bovine collagen or carbon-coated beads

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